As the Covid-19 pandemic ebbs in the United States, the nation is facing a worsening substance use crisis that has led to a rise in overdose deaths. Using a special set of health care billing codes reserved for screenings and short interventions, practicing psychologists can help patients who use alcohol or other substances before a severe outcome occurs.
In the first year of the pandemic, more than 1 in 10 adults reported starting or increasing their use of alcohol or drugsopens in new window to cope with the pandemic. In addition, deaths caused by drug overdose have spikedopens in new window during this public health emergency, primarily driven by opioid use. More Americans died from overdoses in 2020 than in any previous year, and recent data from the Centers for Disease Control and Preventionopens in new window show overdose deaths rose again during the first half of 2021.
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“Data suggest that alcohol use and other substance use have increased amid the Covid-19 pandemic in many areas and for many populations,” said Dolores Cimini, PhD, senior research scientist and director of the Center for Behavioral Health Promotion and Applied Researchopens in new window at the University at Albany. “What this means is that it is especially important now for clinicians to be paying attention to the role of substance use in presenting issues that they encounter with patients.”
APA has been taking steps toward addressing opioid and other substance use from a population health approach by advocating that health care payers reimburse psychologists and other mental health providers for screening, brief intervention, and referral to treatment (SBIRT) services. SBIRT services represent a comprehensive and integrated public health approach to the delivery of early intervention and treatment services. These services can be provided in a variety of settings to help identify people with substance use disorders and those whose usage puts them at a higher risk for severe outcomes, noted Aaron Weiner, PhD, ABPP, president-elect of APA’s Division 50 (Society of Addiction Psychology).
“People are misusing substances far more now than in recent memory, and a lot of independent practitioners may not have a structured clinical interview system in place, so these sorts of things may very well be slipping by,” Weiner said. “Simply asking the question and then knowing what to do if someone said yes could help connect someone to help for a problem that, if you can get to it early, doesn’t have to grow into something that becomes a chemical dependency or an overdose.”
Weiner also noted that being aware of the reimbursement codes used to bill insurers for SBIRT services can help many psychologists get paid for work they’re often already doing.
“Right now, psychologists are leaving a lot of money on the table if they’re only billing for clinical hours,” he said. “Physicians are using these codes, and not only does it provide you with reimbursement for the actual work you’re doing, but it promotes an evidence-based best practice that will hook people into care.”
Moving away from the traditional substance use model
SBIRT services include three core components, noted Stephen Gillaspy, PhD, senior director of APA’s Office of Health Care Financing: screening, brief intervention, and/or referral to treatment. The screening phase is a quick way for psychologists to identify patients with risky substance use behaviors using a brief one- to three-question screen such as the National Institute on Alcohol Abuse and Alcoholism’s single-question screenopens in new window or the quick screen developed by the National Institute on Drug Abuse (NIDA).
If a person screens positive on one of these instruments, practitioners can follow up with a longer alcohol or drug use evaluation using a standardized risk assessment tool such as the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT)opens in new window, Drug Abuse Screening Test (DASTopens in new window), or the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) Tool, developed by NIDA.
“SBIRT moves away from the traditional model of substance use where individuals were designated either as having an addiction or no addiction,” said Cimini, who recently coedited the APA book Screening, Brief Intervention, and Referral to Treatment for Substance Use: A Practitioner’s Guide with Jessica Martin, PhD, an associate professor of counseling psychology at the University at Albany. “SBIRT looks across the spectrum. Patients could be engaging in risky use but may not have an addiction. It’s a broad, all-encompassing view of substance use in all its forms and degrees.”
These screenings can be part of a self-report measure the practitioner gives at the beginning of treatment, or just asked as part of the initial interview at a patient’s first visit, Weiner said.
“The first and most important thing is to ask the questions, because if you don’t ask, you can’t do anything about it,” he said.
If a patient does acknowledge or indicate that they’re using a significant amount of a substance or it seems like they have an addiction-related problem, the next step is to conduct a brief intervention that focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
“The patient needs to be ready to engage in some kind of behavior change; however, we can’t force that change process to happen faster, so the psychologist needs to assess where the patient is in terms of their readiness for change,” Cimini said. “Then the psychologist can use motivational interviewing to help the patient explore the relationship of their substance use to other aspects of their lives.”
For example, if the psychologist is working with a college student who admitted they were using an excessive amount of alcohol, the provider could examine how that behavior may be impacting the student’s performance in school, their grades, and ultimately their graduation and career progression.
“What motivational interviewing does is, it helps create a discrepancy between the substance use and the goals that the individual has, and it will hopefully help them think about changing their behavior,” Cimini said.
During this process, it’s also important for the practitioner to listen for what Cimini calls “change talk,” or anything a patient may say to indicate that they’re ready for change. At that point, you can help them identify specific steps to reduce their substance use. In the example of the college student, for instance, the psychologist could suggest alternating between alcoholic and nonalcoholic drinks in social situations.
“These types of interventions can occur within a time span of a few minutes, while more intensive interventions can take place over a number of sessions,” Cimini said. “That’s really the beauty of SBIRT—it can be adjusted to the needs of the practitioner and their practice.”
The third step of SBIRT is treatment referral, which may be warranted in cases where a higher level of care, such as a specialized addiction program, is needed.
This goes beyond simply sending people to the Alcoholics Anonymous website, Weiner noted. It’s important for psychologists to know, for example, of high-quality intensive outpatient, partial hospitalization, and residential programs in the area, and ideally which programs are covered by different payers.
“If you work with a number of different insurances, make sure you know where to send people so you’re not having to make something up on the fly or you don’t know what to do,” he said.
Using SBIRT for pain management
SBIRT has increasingly been used by mental health providers to help patients dealing with chronic pain. While not all patients with pain develop substance use disorders, and not all patients with substance use disorders have pain, there is a subset of individuals who present with both conditions concurrently, said Ravi Prasad, PhD, a pain psychologist at the University of California Davis School of Medicine.
“Psychologists who are providing SBIRT services should therefore assess for the presence of untreated or undertreated pain, as this is a risk factor that can leave a patient vulnerable for relapse despite participation in substance abuse treatment,” Prasad said. “If pain is identified as an existing comorbidity, it will be important to help the patient learn and apply nonpharmacologic approaches to pain management or to refer them to a psychologist with expertise working with pain who can address this aspect of treatment.”
In the instance of chronic pain patients, however, it’s important that practitioners not stigmatize this population or inaccurately conclude that they are all at high risk for developing substance use disorders. “Of course, there is a subset of these individuals who are at risk for developing substance use disorders, and psychologists working in this field should regularly assess for this as part of the evaluation process. SBIRT services can be an efficient and effective way to accomplish this,” Prasad noted.
Mindset shift
Even though psychologists have the skills and training necessary to effectively deliver SBIRT services, the reality is that most of them do not know about SBIRT, nor the availability of reimbursement from insurers to support this work, Martin said.
Being willing to provide these services may require a mindset shift for many in the field, Gillaspy said.
“Too often, psychologists and other mental health providers just think about traditional treatment for an individual patient who is coming to see them—for anxiety, or depression, or posttraumatic stress disorder—in a bit of a bubble,” he said. “I don’t think it’s as widely thought of to take this opportunity to ensure they screen and provide brief interventions for other issues the patient might have. Or to think that, even if you’re not a specialist in a particular area, you can still determine if it’s an issue, have a brief intervention with them, and then, if they need additional help, refer them to appropriate substance use services.”
Screening and providing brief interventions to every patient is more of a public health approach to address population health, he added.
Weiner agrees, adding that by not asking about substance use, gambling, pornography use, or issues such as gaming and internet-related disorders, practitioners may be missing an incredibly important piece of the coping puzzle, making it difficult for any mental health interventions to be effective.
“The bottom line about SBIRT is that it’s a technique that almost always, when done in an evidence-based way, leads to a greater proportion of people being helped who otherwise wouldn’t,” he said. “And given that it can be done in a very short period of time, it’s something that is simply worth doing.”
